BlueMedicare Value (PPO)

BlueMedicare Value (PPO) H5434-034 Plan Details
3.5 out of 5 stars

BlueMedicare Value (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Guidewell Mutual Holding Corporation.
Plan ID: H5434-034.

$0.00
Monthly Premium

BlueMedicare Value (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Guidewell Mutual Holding Corporation.
Plan ID: H5434-034.

BlueMedicare Value (PPO) H5434-034 Plan Details
3.5 out of 5 stars

BlueMedicare Value (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Guidewell Mutual Holding Corporation.
Plan ID: H5434-034.

$0.00
Monthly Premium

Florida Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $150
Out of Pocket Max In-Network: $4000
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00 to $10.00
Out-of-Network:

Doctor Office Visit:
Coinsurance for Medicare Covered Primary Care Office Visit 50%
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $35.00 to $48.00
Out-of-Network:

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 50%
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$275.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 50%
Urgent Care
Copayment for Urgent Care $40.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $125.00
Maximum Plan Benefit of $25,000
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 48 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $125.00
Maximum Plan Benefit of $25,000
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $305.00

Air Ambulance:
Copayment for Air Ambulance Services $305.00

Except for emergency care, prior authorization is required for ambulance services, in-network only. Contact Member Services for more information.
Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $305.00
Copayment for Medicare Covered Ambulance Services - Air $305.00

Health Care Services and Medical Supplies

BlueMedicare Value (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $20.00
Out-of-Network:
Coinsurance for Medicare Covered Chiropractic Services 50%
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0.00
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00
Out-of-Network:
Coinsurance for Medicare Covered Diabetic Supplies and Services 50%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Durable Medical Equipment 50%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $75.00
Copayment for Medicare-covered Lab Services $0.00 to $40.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $50.00 to $150.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $15.00 to $150.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 50%
Coinsurance for Medicare Covered Lab Services 50%
Coinsurance for Medicare Covered Diagnostic Radiological Services 50%
Coinsurance for Medicare Covered Therapeutic Radiological Services 50%
Coinsurance for Medicare Covered Outpatient X-Ray Services 50%
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Home Health 50%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$318.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 50%
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $20.00
Copayment for Medicare-covered Group Sessions $20.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Individual Sessions 50%
Coinsurance for Medicare Covered Group Sessions 50%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $225.00

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $90.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $150.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 50%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 50%
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $20.00
Copayment for Medicare-covered Group Sessions $20.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Individual or Group Sessions 50%
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $50.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit

Out-of-Network: N/A

Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $35.00
Out-of-Network:
Coinsurance for Medicare Covered Podiatry Services 50%
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$160.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 50%

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 2 visits every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 2 visits every year
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Comprehensive Dental:
Copayment for Medicare-covered Benefits $35.00 to $48.00
Copayment for Extractions $0.00
  • Maximum 2 visits every year
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00
  • Maximum 2 visits every year
Prior Authorization Required for Comprehensive Dental
Prior authorization required
Out-of-Network:

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 50%
Non-Medicare Covered Dental Services:
Coinsurance for Non-Medicare Covered Preventive Dental 50%
Coinsurance for Non-Medicare Covered Comprehensive Dental 50%

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00 to $48.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Maximum Plan Allowance of $200.00 every year for all Non-Medicare covered eyewear for in and out of network services combined
Out-of-Network:

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 50%
Coinsurance for Medicare Covered Eyewear 50%
Non-Medicare Covered Vision Services:
Coinsurance for Non-Medicare Covered Eye Exams 50%
Coinsurance for Non-Medicare Covered Eyewear 50%

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $35.00 to $48.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 1 visit every year

Hearing Aids:
Copayment for Hearing Aids $0.00
  • Maximum 2 Hearing Aids every year
Maximum Plan Benefit of $750.00 every year per ear for in and out of network services combined
Up to 2 hearing aids every year. Hearing aids must be purchased through NationsHearing to receive in-network benefits. Member is responsible for any amount after the benefit allowance has been applied.
Out-of-Network:

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 50%
Non-Medicare Covered Hearing Services:
Coinsurance for Non-Medicare Covered Hearing Exams 50%
Coinsurance for Non-Medicare Covered Hearing Aids 50%

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetic Prevention Program
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Health and wellness education programs
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
Flu shotsHepatitis B shotsPneumococcal shots
Tobacco use cessation
Yearly "Wellness" visit


Out-of-Network:

Medicare-covered Zero Dollar Preventive Services:
Coinsurance for Medicare Covered Medicare-covered Preventive Services 50%

Prescription Drug Costs and Coverage

The BlueMedicare Value (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $150 (excludes Tiers 1, 2 and 6) per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $150 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Standard retail $0.00
  • Standard mail order $0.00
Generic
  • Standard retail $8.00
  • Standard mail order $8.00
Select Care Drugs
  • Standard retail $0.00
  • Standard mail order $0.00
Annual Drug Deductible $150 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Standard retail N/A
  • Standard mail order N/A
Generic
  • Standard retail N/A
  • Standard mail order N/A
Select Care Drugs
  • Standard retail N/A
  • Standard mail order N/A
Annual Drug Deductible $150 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Standard retail $0.00
  • Standard mail order $0.00
Generic
  • Standard retail $24.00
  • Standard mail order $24.00
Select Care Drugs
  • Standard retail $0.00
  • Standard mail order $0.00